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PPH > PPH > Flashcards

PPH Flashcards

1
Q

Blood changes in preg physiologic

A

40% increase plasma volume

25% increased red cell mass

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2
Q

Def of PPH

A

Not much agreed upon:

  1. 500 in SVD, 1000 in C/S
  2. 10% reduction in Hct
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3
Q

How much of blood volume loss before hypotension, dizziness, pallor, oliguria occur?

A

10%

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4
Q

Main sx of genital tract hematomas

A

pelvic/rectal pressure/pain

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5
Q

Primary vs Secondary PPH

A

Primary w/in 24 hrs s/p delivery

Secondary 24hrs to 12 wks pp

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6
Q

Causes of Primary PPH

A

Uterine atony
Retained products (accreta)
Defects in coagulation
Uterine inversion

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7
Q

Causes of Secondary PPH

A

Subinvolution
Retained Products
Infection
Inherited coag defects

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8
Q

Red tube test

A

5mL of pts blood into tube, should clot in 8-10 min if fibrinogen is normal…if fibrinogen is low (

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9
Q

What conditions can cause clotting abnormalities?

A 
HELLP
prolonged fetal demise
sepsis
AFE
placental abruptions
significant hemorrhage (consumes clotting factors)
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10
Q

Risk factors for PPH

A
  1. Prolonged labor
  2. Rapid labor
  3. Augmented labor
  4. H/o PPH
  5. Distended uterus (twins, macrosomia, hydramnios)
  6. Operative delivery
  7. Episitomy esp Mediolateral
  8. Asian/hispanic
  9. Chorio
  10. PreE
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11
Q

Large bore iv

A

16 gauge

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12
Q

Uterotonics/doses

A
  1. methergine 0.2mg IM (maybe IU) q2-4 hrs; max 5 doses?
  2. hemabate (PGF2a) 0.25mg IM (IU?) q15-90 min, max 8 doses
  3. Cytotec (misoprostol/PGE1): 800-1000mcg/rectum (sublingual 10, 100mcg tabs or 5 200mcg tabs)
  4. Pitocin 10-40 units in 1L NS or LR continuous rapid infusion or 10 units IM
  5. Dinoprostone (PGE2) 20mg per rectum/vagina q 2 hrs
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13
Q

Uterotonic contraindication or side effects

A
  1. methergine (HTN)
  2. hemabate (asthma; relative CI renal, cardiac, hepatic disease; can cause diarrhea, fever, tachy)
  3. cytotec: can cause fever
  4. dinoprostone: avoid with HYPOtension, fever common; stored frozen, must be thawed to room temp
  5. pit: avoid undiluted rapid iv infusion –> hypotension
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14
Q

B-Lynch suture?

A

1-#2 catgut on large mayo needle, something that absorbs quickly so bowel does not get caught when uterus involutes

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15
Q

Oleary stitch

A 
#0 polygycolic acid suture (vicryl), large blunt needle (5 Mayo)--into lower uterine segment as close to cervix as possible laterally come out around uterine artery or uetero ovarian artery branches through the broad ligament--good if uterine artery has been ligated...will not stop bleeding for uterine atony/accreta...may decrease blood loss while other interventions attempted.
Identify the ureter!!
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16
Q

What if Oleary stitch does not slow bleeding?

A

Similar stitch across utero-ovarian arcade right by cornua

17
Q

Uterine packing/tamponade techniques

A
  1. foley bulb: fill 60-80cc NS, 1 or more bulbs
  2. Blakemore-Sengstaken tube
  3. Bakri: 300-500ml NS
  4. uterine tamponade
  5. packing: cornu to cornu, 4 inch gauze (soak 5K units of thrombin in 5 mL sterile saline
18
Q

When would you consider packing/tamponade?

A

when uterotonics fail to cause sustained uterine ctxns and satisfactory control of hemorrhage after vaginal delivery, temporizing, but if prompt response not seen, preparations should be made for XLAP

19
Q

Hypogastric artery ligation successful?

A

Now found to be less successful than previously thought difficult, more for ppl with experience in this technique

20
Q

Risk factors for placenta accreta

A
  1. over 35yo
  2. asherman’s
  3. previous uterine surgery: c/s; myomectomy
  4. submucous fibroids
21
Q

How do you do a hypogastric artery ligation?

A
  1. open anterior leaf of broad ligament and lyse areolar tissue of the retroperitoneum
  2. identify external iliac, follow up to common
  3. now find internal iliac (about 4cm before splits into ant/post), identify anterior/posterior branches
  4. You try to ligate the anterior branch…but a lot of the time you will just ligate the whole internal iliac
  5. use permanent suture (polypropylene) or #1 silk go from lateral to medial, tie artery securely
22
Q

What are some major complications of internal iliac artery ligation?

A
  1. you can ligate the external iliac –> ipsilateral leg (check dorsalis pedis/posterior tibial pulse!)
  2. accidentally lacerate internal iliac vein (just behind and medial to internal iliac artery) or external iliac artery (lateral) = exangunation
23
Q

Heparin works on what pathway
Warfarin works on which pathway
PT/PTT? pathways?
Factors that start off each pathway?

A

PET=Extrinsic –> Warfarin –> VII

PITT = Intrinsic –> Heparin –> XII

24
Q

Packed RBC Volume, increase hgb/hct?

A

240mL

3% hct, 1g/dL Hgb

25
Q

Platelets volume, increase plts?

A

50mL

5-10,000 increase

26
Q

FFP, volume, factors it contains, raise in Fibrinogen

A

250mL
Fibrinogen, Factor VIII and V, antithrombin III
10 mg/dL raise

27
Q

Cryoprecipitate, volume, factors, raises what?

A

40mL
Fibrinogen, Factor VIII and XIII, von Willebrand factor
10mg/dL raise FIBRINOGEN

28
Q

Risk of prior c/s with accretas

A
  1. 2% s/p 1st c/s
  2. 3% 2nd
  3. 6% 3rd
    - —————
  4. 1 % 4th
  5. 3% 5th
  6. 7% 6th
29
Q

Risk of accreta with Previa present and prior c/s

A 
1st 3%
2nd  11%
3rd  40 %
4th  61%
5th 67%
30
Q

When can you call IR for arterial embolization?

A

stable vitals, persistent bleeding (and if it is not excessive)
Can be used to preserver fertility

31
Q

In what situation is autologous transfusion considered?

A

Person with rare antibodies

32
Q

Risk factors for uterine rupture

A 
small uterine horn
operative delivery
placenta accreta
abnormal labor
prior c/s
33
Q

Should you repair uterine rupture?

A

If possible to preserve fertility

34
Q

Inverted uterus management

A

Try to push it back up: holding a tennis ball, palm to fundus
May need to relax uterus: mag, terb, halogenated anesthetics, nitroglycerin

35
Q

What happens if cannot manually revert uterus?

A

Rare situation
OR for exploration: Huntington’s: use babcocks/allis clamps on fundus and pull up
Haultain: cervical ring incision posteriorly, then digital repositioning of inverted corpus

PPH (1 decks)

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